GLOBAL DENTAL RELIEF DONATIONS

Please fill out the form below and options for paying will be displayed. Credit card is via paypal.

DONATION FORM:
1)  Yes, I want to contribute:
Please check one.

$   50             Provide five children with first-time dental care.
$ 100             Provide ten children with first-time dental care.
$ 500             Bring dental care to a first-grade class of 50 children.
$1000            Provide first-time care to 100 children living in an orphanage.
$2500            Sponsor a local school of 250 children in the country of your choice with first time and follow-up care.
$5000            Sponsor a six day dental clinic in the country of your choice, serving 500-1000 children.

Type of payment: PayPal Check Select One *

Global Dental Relief is a 501(c ) 3 charitable organization.

2)  Please send more information.  I am interested in volunteering as a:   Select One Dentist Dental Assistant Hygienist Non-medical   

3)   I would like to volunteer in Select One Nepal Vietnam Ladakh, India Guatemala Kenya

4)   I want to help in other ways:
Donating Supplies
Recruiting Volunteers
Administrative Support in the US
Other:  please specify

5)  Contact information:

First Name:		*
Last Name:		*
Address:
City:
State:
Zip:
Email Address:		*
Telephone:
Comments:

THANK YOU FOR YOUR SUPPORT!